1. Home
  2. Low Back Pain

Low Back Pain

Low Back Pain A Review

Author/s: 
Aidan G. Cashin, Roger Chou, Melissa B. Weimer

Abstract
Importance Low back pain is defined as pain localized below the costal margin and above the inferior gluteal fold, with or without leg pain. Low back pain affects approximately 619 million people worldwide and is the leading cause of years lived with disability worldwide.

Observations Approximately 90% of patients presenting for care with low back pain have nonspecific low back pain, which is defined as low back pain that is not associated with specific spinal disorders (such as lumbar radiculopathy, lumbar spinal stenosis, vertebral fracture, axial spondyloarthritis, infection, or malignancy). Low back pain is classified as acute if the duration is shorter than 6 weeks, subacute if the duration is 6 to 12 weeks, and chronic when the duration is longer than 12 weeks. The age-standardized prevalence of low back pain is higher in females (9330 per 100 000) than in males (5520 per 100 000). The prevalence of low back pain increases with age, peaking at approximately 85 years. Risk factors for low back pain include obesity, depressive symptoms, occupational exposures (eg, heavy lifting), tobacco use, chronic disease (eg, diabetes), and previous low back pain. Acute nonspecific low back pain is usually self-limited, and approximately 72% of individuals recover by 12 months. Prognosis is less favorable for chronic nonspecific low back pain, but 42% of patients recover within 12 months. Initial management of patients with low back pain of any duration includes reassurance that serious underlying disease is unlikely, discussion about the expected time course of recovery, and the recommendation to remain physically active. Patients should be encouraged to continue their usual activities (including work), avoid prolonged rest, and be advised to self-manage their condition, which consists of symptom-relief strategies (such as heat application) and activity pacing (maintaining or gradually increasing usual activities and work). For patients with acute nonspecific low back pain, first-line therapies include heat application, spinal manipulation, massage, and acupuncture (typically provided by physical therapists, chiropractors, acupuncturists, and massage therapists) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; such as ibuprofen) and skeletal muscle relaxants (such as cyclobenzaprine). For chronic nonspecific low back pain, first-line therapies include exercise of any type, psychological therapies (eg, cognitive behavioral therapy), or combined multidisciplinary approaches (such as pain management programs and integrated exercise and psychological care) along with spinal manipulation, massage, and acupuncture. NSAIDs should be considered as second-line therapy for chronic nonspecific low back pain.

Conclusions and Relevance Low back pain is a leading cause of disability worldwide. Acute nonspecific low back pain is often self-limited, whereas chronic nonspecific low back pain has a less favorable prognosis. For patients with acute nonspecific low back pain, first-line treatments include selected nonpharmacological therapies and medications (such as NSAIDs and skeletal muscle relaxants). For patients with chronic nonspecific low back pain, first-line treatment consists of exercise, psychological therapies (such as cognitive behavioral therapy), and combined multidisciplinary care.

Keywords 
Low Back Pain Nonspecific Low Back Pain

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Author/s: 
Sayed, D., Grider, J., Strand, N., Hagedorn, J. M., Falowski, S., Lam, C. M., Francio, V. T., Beall, D. P., Tomycz, N. D., Davanzo, J. R., Aiyer, R., Lee, D. W., Kaila, H., Sheen, S., Malinowski, M. N., Verdolin, M., Vodapally, S., Carayannopoulos, A., Jain, S., Azeem, N., Tolba, R., Chien, G. C. C., Ghosh, P., Mazzola, A. J., Amirdelfan, K., Chakravarthy, K., Petersen, E., Schatman, M. E., Deer, T.

Introduction
Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective
The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods
The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results
After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion
The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Keywords: back pain, intervention, clinical guideline, spinal cord stimulation, minimally invasive spine procedure, lumbar disorder, epidural steroid injection, radiofrequency ablation

Keywords 
evidence-based interventional treatments Low Back Pain lumbar spinal disorders Pain

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care

Author/s: 
Stevans, Joel M., Delitto, Anthony, Khoja, Samannaaz, Patterson, Charity G., Smith, Clair N., Schneider, Michael J., Freburger, Janet K., Greco, Carol M., Freel, Jennifer A., Sowa, Gwendolyn A., Wasan, Ajay D., Brennan, Gerard P., Hunter, Stephen J., Minick, Kate I., Wegener, Stephen T., Ephraim, Patti L., Friedman, Michael", Jason M., Robert B.

Importance: Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.

Objective: To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.

Design, setting, and participants: This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.

Exposures: SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).

Main outcomes and measures: Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.

Results: Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).

Conclusions and relevance: In this cohort study, the transition rate to chronic LBP was substantial

Keywords 
back pain primary care Low Back Pain opioids LBP SBT
Subscribe to Low Back Pain